Telemedicine Consent

Telemedicine Consent
COMPETENT COMPASSIONATE CARE
I hereby authorize Dr. Gregory Wheeler to use telemedicine (telephone, email, text, and fax) in the course of my diagnosis and treatment. I understand that telemedicine involves the communication of my medical information orally via phone, internet or other telemedical devices to myself, as well as, potentially to other physicians and other health care practitioners located in other parts of the state or outside of the state.

I understand that I have all the following rights with respect to telemedicine:

Patient Choice of Care. I have the right to withhold or withdraw my consent to telemedicine at any time without affecting my right to future care or treatment and without risking the loss of my health coverage.

Access to Information. I have the right to inspect all medical information transmitted during a telemedicine consultation; and may receive copies of this information for a reasonable fee.

Confidentiality. I understand that the laws which protect the confidentiality of medical information apply to telemedicine; and that no information or images from the telemedicine interaction which identify me will be disclosed to researchers or other entities without my consent.

Potential Risks. I understand that there are risks from telemedicine, including the possibility, despite reasonable and appropriate efforts, that: the transmission of medical information could be disrupted or distorted by technical failures in transmission; the transmission of medical information could be interrupted by unauthorized persons. In addition, I understand that telemedical examinations or care may not be as complete as face-to-face examinations or care and that telemedicine does not negate or minimize the risks that may be inherent in a consultation.

Finally, I understand that it is impossible to list every possible risk, that my condition may not be cured or improved, and sometimes, may get worse.
Initial *
Consequences. I understand that by consenting to telemedicine my physician may communicate medical information concerning me to physicians and other health care practitioners located in other parts of the state or outside the state.

Benefits. I understand that I can expect benefits from telemedicine, but that no results can be guaranteed or assured. [Where applicable: Telemedicine provides me with access to medical care that otherwise would not have been available.]

I have read and understand the information provided above, I have discussed it with my physician or my physician's designee, and all my questions have been answered to my satisfaction.
Date *

Month Day Year
Date
Signature of patient / parent / guardian *

Clear
Print Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date Of Birth *

Month Day Year
Provide date of birth
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Please select urgent only if you are SICK. Urgent visits for same day or next business day, please mark as urgent so that you can be evaluated sooner. We will do our best to get back to you.

***PLEASE note that if you are at all uncomfortable with how you feel, seek IMMEDIATE treatment in an Emergency Room. This site is not an equivalent or a replacement for an ER especially for life threatening conditions.***
Is this an **URGENT** visit (Check Yes if same day or next business day needed)? *

Yes No
Family Information (Name, Date of Birth, Allergies, Medical Problems, Weight)
For persons paying for a family plan with multiple family members requiring treatment
Please include your vital signs which need to be as accurate as possible. This section is very important for your safety and accurate diagnosis (please put NA if unavailable).
Temperature *
Degrees Fahrenheit
Pulse Rate *
Heart beats per minute?
Respiration Rate *
How many breaths per minute?
Blood Pressure *
What is your blood pressure?
Pulse Oximetry *
What is your oxygen saturation?
Please complete the additional medical history. Please be as thorough as possible.
Gender *

Male Female
Weight *
Weight in Pounds
Pregnancy Status *

Not Pregnant Pregnant Menopause
Recent Covid-19 Test *

Positive Negative Not Applicable
Allergies *
Medications and reaction
Current Medications *
Prescription, herbals and over the counter
Medical History *
Past or current medical diagnosis
Surgical History *
Past Surgeries
What are your symptoms? *
List your symptoms
Social History *

None Smoker Alcohol Drug Use
Length of symptoms *
How long have you had your symptoms?
What have you done? *
List medications and other treatments you have tried to relieve your symptoms
COVID-19 vaccine? *
Have you have taken the vaccine? If yes, which one?
**Important Pharmacy Information. Please read.

You have the best knowledge of your local pharmacies. The process is **MUCH QUICKER** and useful for you to make calls to these pharmacies. Not all pharmacies will fill these medications. Please look for a privately owned pharmacy, and verify that they will fill the medication that you desire. Otherwise, there will be a delay in filling your script. We **CANNOT** make calls verifying that a pharmacy will fill your script due to high volumes.
Pharmacy Name *
Pharmacy Name
Pharmacy Address *
Pharmacy Address
** Please get the FAX number from your pharmacy as we fax scripts. We will also send you an email copy of the script that we send**
Pharmacy Fax Number *
Pharmacy Phone
Attestation *

I attest that all information is true and correct to the best of my knowledge
Please select a service level *
prev next ( X )
Telehealth Sick Visit Provider visit via telehealth platform for management of active CV-19 infection
$ 150.00

Telehealth Preventative Visit Provider visit via telehealth platform for CV-19 prevention protocol
$ 150.00

Telehealth Follow-up Visit Provider visit via telehealth for ESTABLISHED patient follow-up
$ 90.00

Family Visit Provider visit via telehealth for CV-19 for families of 2 or more persons.
$ 300.00

Total

$ 0.00
Should be Empty:

Telemedicine Consent

COMPETENT COMPASSIONATE CARE

Please select urgent only if you are SICK. Urgent visits for same day or next business day, please mark as urgent so that you can be evaluated sooner. We will do our best to get back to you.

Please include your vital signs which need to be as accurate as possible. This section is very important for your safety and accurate diagnosis (please put NA if unavailable).

Please complete the additional medical history. Please be as thorough as possible.

**Important Pharmacy Information. Please read.